Fresh Start Questionnaire

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Incarcerated and Detained Application

First Name This is required

Last Name This is required

Doc Number This is required

Complete DOC Address This is required

Phone Number if available Enter your phone number Enter a valid number like +1555-123-4567

Social Security Number This is required

Date of Birth This is required

Marital Status This is required

First Name This is required

Last Name This is required

If married tell us a little about the situation: This is required

Legal Status: What county are you supposed to parole to? (What county did you get convicted in, what county is your plan supposed to be in) This is required

What was the conviction for? This is required

Do you have any sexually related offense(s): This is required

Do you have any violent offense(s): This is required

Do you have any drug related charge(s): This is required

Name of current institution Probation/Parole Officer or Case Worker if you know who it is: This is required

Phone and Extension Enter your phone number Enter a valid number like +1555-123-4567

Are there any circumstances regarding your Probation/Parole? This is required

What is your expected release date? How certain is that? This is required

How much time have you served this incarceration? This is required

How much time total have you spent incarcerated in your life? This is required

Past drug or alcohol use: This is required

Have you ever been in a drug or alcohol treatment program? If yes how many? This is required

What type of drugs have you dealt with? This is required

Are you taking prescription medication? If yes why are you prescribed medication? (Explain purpose) This is required

Name the medication(s) you take: This is required

When was your last doctor's appointment for your medication(s)? This is required

Have you ever been admitted to a mental facility or a mental treatment program? If yes where, how long and for what? This is required

Spirituality: Do you see God as a part of your life? If yes explain. This is required

Past work experience? Explain. This is required

Relationships: Are you in a committed "romantic" relationship? If yes, how long, do you feel its a healthy relationship and why or why not? This is required

How many kids do you have? This is required

Do you have a relationship with your kid(s)? This is required

Emergency Contact: This is required

Emergency Contact Relationship: This is required

Emergency Contact Phone Number: Enter your phone number Enter a valid number like +1555-123-4567

Why do you want to live at the Fresh Start House? This is required

Do you feel you have a problem with decision making, alcohol or drugs? Explain. This is required

List a few short term goals for your life (the next six months): This is required

Please state any other information that you thinik might be helpful so that we can serve you better: This is required

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Fresh Start Questionnaire

Incarcerated and Detained Application